Uroradiology in the fetus and newborn: diagnosis and follow-up of congenital obstruction of the urinary tract.

Abnormalities of the fetal urinary tract, most commonly hydronephrosis of differing causes, can be detected by ultrasound (US). Prenatal measurements of the kidney can help to predict the postnatal outcome of hydronephrosis. About 20% of abnormalities evident in utero are not present after birth. After delivery, various imaging procedures, particularly US and voiding cystourethrography may be necessary to evaluate prenatally diagnosed abnormalities. Pyelectasis may be due to obstruction and this may be assessed by sonography during diuresis, urography or diuretic renography. Renography can also evaluate global and split function of the kidneys. 123I-hippurate and 99 mTc-MAG3 are superior to 99 mTc-DTPA, but there is no 'gold standard' technique available to assess obstruction. The majority of cases of hydronephrosis, even those which appear to be due to obstruction, can be treated conservatively without deterioration of renal function. Primary megaureter is the second most common cause of obstructive hydronephrosis in the newborn. The diagnostic procedures are similar if the dilated ureter persists unchanged and the infant is asymptomatic. Newborns with antenatally detected renal abnormalities frequently have associated vesicoureteric reflux.

Renal scars and parenchymal thinning in children with vesicoureteral reflux: a 5-year report of the International Reflux Study in Children (European branch).

A total of 321 children less than 11 years old with nonobstructive grade III or IV vesicoureteral reflux and with previous urinary tract infection was randomly allocated to medical or surgical treatment in the European branch of the International Reflux Study in Children. (Randomization was stratified for age, sex, grade of reflux, presence of renal scarring, interval since last urinary tract infection and treating hospital). The results of excretory urography are reported for 233 girls and 73 boys treated according to the random allocation, 89% of whom were followed for 5 years. After 5 years in the medical group (155 children) new renal scars were seen in 19 and new renal parenchymal thinning in 11. The proportions were almost identical among 151 children allocated to surgical treatment with 20 new scars and 15 new thinnings. Progression of established scars was also similar in both groups. However, the new scars developed sooner after surgery than during medical treatment. In 6 surgically treated children postoperative obstruction was followed by the development of new scars. In addition, 12 patients showed new scars approximately 6 months after successful surgery, while in only 2 children scars developed more than 6 months after surgery. In 11 children of the medical group new scars were seen more than 6 months after allocation. More new scars developed in the children with parenchymal thinning at entry (23%) than in those with scarred or normal kidneys at entry (10% each) (p < 0.05). The younger the patients at entry, the higher the frequency of new scars (less than 2 years 19.8%) 2 to 4 years 9.8% and 5 years or more 4.6%, p < 0.05).

Cessation of vesicoureteral reflux for 5 years in infants and children allocated to medical treatment. The International Reflux Study in Children.

A total of 401 children with severe vesicoureteral reflux (97 with grade III and 304 with grade IV) was entered into the European branch of the International Reflux Study in Children. Of these patients 37 with grade III and 43 with grade IV reflux were allocated to medical treatment as a sideline group because the reflux grade III or IV had improved to grade II or I, or it had disappeared during the preceding 2 to 6 months (median 4). Of the remaining 321 patients with persistent grade III or IV reflux 158 were randomly allocated to medical treatment of whom 3 switched to surgery. We report on 235 children treated medically (155 random medical and 80 sideline), of whom 88% had a complete 5-year followup with x-ray and/or isotope voiding cystourethrography at 6, 18, 30 and 54 months. Seven children dropped out of the study after a followup of 6 months or less, including 6 with persistent vesicoureteral reflux. Cessation of vesicoureteral reflux was observed significantly more often in children with unilateral (40 of 74, 54%) than with bilateral (18 of 154, 12%) reflux (p < 0.001). No significant difference between grades III and IV was noted. Vesicoureteral reflux ceased in 25 of 153 children (16%) from the random medical group and in 32 of 75 children (43%) in the sideline group. Of 194 children with vesicoureteral reflux detected for the first time at entry reflux resolved in 55 (28%). In only 2 of 34 children (6%) in whom vesicoureteral reflux was detected more than 1 year before entry did reflux resolve after 5 years. Among the children in whom vesicoureteral reflux either disappeared, diminished or remained unchanged the proportion with urinary tract infection recurrences was almost the same.

[About the problem of congenital laryngo-tracheo-esophageal cleft]. / Zur Problematik der kongenitalen laryngotracheoösophagealen Spalte.

The congenital laryngo-tracheo-oesophageal cleft is an extremely rare anomaly representing an incomplete or absent separation of larynx and trachea from the oesophagus. Depending on the extent of the anomaly, the phenomenon is classified into laryngeal cleft (type I), cleft affecting the superior part of the trachea (type II) and defect extending to the bifurcation (type III). We report on 3 cases. A boy with a type II cleft died at the age of two days due to respiratory insufficiency conditioned by aspiration, before surgery would have been possible. In another boy with a type II cleft closure was successfully performed in several sessions. A girl with a type III cleft died at the age of five months after the defect had been almost completely closed in two sessions. The right main bronchus and the right lung were hypoplastic and also the left main bronchus was partly represented by skin formation only. This resulted in progressive respiratory insufficiency. Both boys had an associated malformation of the G syndrome type. Despite the unhappy outcome of the last of three cases mentioned above, it seems that stepwise closure is less associated with surgical risk than surgery in a single session. A review of the 24 cases of cleft described in the literature shows that these children present very serious treatment problems and that there is a high incidence--amounting to 60%--of associated malformations, especially of the lungs and bronchi.

[Long-term results following hepatico-jejunostomy with antireflux valve construction in congenital bile duct dilatation caused by abnormal junction of the choledochus]. / Langzeitresultate nach Hepatiko-Jejunostomie mit antirefluxiver Klappenbildung bei kongenitaler Gallengangsdilatation infolge Choledochusfehlmündung.

Cystic-cylindrical dilatation of the intrahepatic and extrahepatic bile ducts occurs rarely in childhood. Aetiologically, congenital pancreaticobiliary junction anomalies play a decisive part. Accurate preoperative diagnosis is by no means an easy matter. The best possible diagnostic approach to clarify the pathologico-anatomic conditions consists in sonography coupled with on-target partial intraoperative cholangiography presenting the preduodenal section of choledochus and pancreatic duct. Between 1979 and 1987 surgery was performed at the Paediatric Surgical Department of the Municipal Paediatric Hospital of Cologne on 18 patients suffering from intrahepatic and extrahepatic cysticocylindrical dilatation of the bile ducts due to confirmed ectopic pancreaticobiliary junction anomaly. This study does not include all other types of choledochus cysts or biliary duct dilatations without proven pancreaticobiliary junction anomaly. The treatment of choice is the resection of the dilated extrahepatic biliary ducts followed by hepatico-jejunostomy using the Roux-en-Y technique. To avoid cholangitis due to reflux of intestinal contents via the shunted jejunum loop, we are constructing a two-stage anti-refluxive muscular mucosa valve in the shunted loop; this practice has been followed by us since 1983. Permanent postoperative freedom from cholangitis in 10 children after construction of the valve prompts us to recommend this procedure also in other types of bile duct surgery, especially in the treatment of atresias.

Imaging of uretero-pelvic junction obstruction with stimulated diuresis. With consideration of the reliability of ultrasonography.

Eighty-nine kidneys of 81 infants and children with uretero-pelvic junction obstruction were investigated using ultrasonography (US), diuretic urography (DUR) and diuretic renography (DREN). Results of the US were false-negative in 14%. This can be avoided by ensuring that the patients get an amount of fluid appropriate to their age before the examination or by performing diuretic ultrasonography with frusemide. False-positive results were found with US in 15%, but obstruction was excluded by using the DUR and/or the DREN. During post-operative follow up the DUS is useful and after 6 months the clearance with 123-iodine hippurate combined with the DREN should be performed. The performance of the Whitaker-test is unnecessary.

[Lobar emphysema]. / Lobäremphysem.

The lobes most commonly affected are the left upper and the right middle lobes. The classical sign of respiratory distress is mainly found within the first two months of life. In 14 infants the diagnosis was confirmed by microscopic examination, 13 were treated by surgery and 4 infants, who had associated serious malformations or complications, died. In most cases hypoplastic bronchial cartilage of the concerned bronchi was seen, in some cases a stenosis of the lobar bronchi. It is of great importance to establish the diagnosis as soon as possible. The lobectomy is recommended if the respiratory or cardial failure is worsening despite artificial ventilation.

[Roentgenologic findings in chronic bronchopulmonary diseases in children]. / Röntgenologische Befunde bei chronischen broncho-pulmonalen Erkrankungen im Kindesalter.

X-ray findings in chronic bronchopulmonary diseases in children are presented on the basis of observations made during the last 20 years. Six groups of diseases can be differentiated according to signs and clinical course: Pneumonias with delayed healing, chronic relapsing infiltrations, mucoviscidosis, chronic pleuropneumonia with abscess formation, chronic interstitial processes and chronic infiltrations with bronchiectasis. The typical phenomena and possibilities of differential diagnosis are discussed.

[Abnormal choledocho-pancreatico ductal junction causative of cystic-cylindric dilatation of intra- and extrahepatic bile ducts]. / Fehlmündung des Ductus choledochus in den Ductus pancreaticus als Ursache der zystisch-zylindrischen Dilatation der intra- und extrahepatischen Gallenwege.

During the last 5 years there were 6 patients found to have abnormal ductal junction of the choledochus into the pancreas. Clinical signs were: repeating upper abdominal pain, intermittent icterus, signs of pancreatitis and/or palpable tumor. Sonography is the initial examination to show up a dilatation of the intra- and extrahepatic bile ducts. But intraoperative cholangiography alone reveals the true condition of the choledocho-pancreatico ductal junction. Only after this procedure the therapeutic step of a choledocho-jejunostomy should be done.

[Diagnostic radiology of the thymus in children (author's transl)]. / Zur Röntgendiagnostik des Thymus im Kindesalter.

Statements based on the observation of 5 cases. Diagnosis by radiology is difficult in: 1) Thymic hyperplasia of unusual size and shape, 2) presence of a "thymus-shadow" beyond the second year of life. 3) Presence of stridor attributed to hyperplasia of the thymic gland. 4) Atypical location of the thymus. Probatory application of steroids can be diagnostically valuable, should however, be applied and interpreted critically. In dystopic forms, especially when localised in the posterior mediastinum, thoracotomy so far has been the only reliable diagnostic method.

Roentgen findings in fractures of the vertebral column in childhood examination of 35 patients and its results.

In the past 10 years we examined 35 children with fractures of the spine. The most important cause was an injury by a fall from a tree or a climbing stage (23 cases). Traffic accidents or other direct trauma was the cause in 10 patients. Two children had tetanus, The ages of the children range from 2 to 12 years. Clinical symptoms may be diagnostic of vertebral trauma, but quite often symptoms are insignificant or atypical. We detected fractures in every vertebra of the thoracic and lumbar part of the spine. The greatest number of fractures was found between T4 and L2. The typical injury of the spine is a compression fracture of the vertebral body with a wedgeshaped deformity (111 vertebrae); fractures of the transverse processus of lumbar vertebrae were not frequent (10 vertebrae). Other parts of the vertebrae were not involved. The value of scintigraphy in case of doubtful roentgenologic finding is pointed out.

Radiological diagnosis of anorectal malformations.

With the help of a few examples, it has been shown that radiological investigations of anorectal malformations with or without a fistula depend on the momentary state of contraction of the muscles of the pelvic floor. If this is not considered, mistakes will be made.

[Radiologic diagnosis of mega-ureter in childhood (author's transl)]. / Die Röntgendiagnostik des Megaureters im Kindesalter

For the radiologic diagnosis of mega-ureter the degree of filling of the bladder (bladder-phenomenon) in the IVP has to be considered. A film, after emptying the bladder, prevents mistaken diagnosis. In order to prove reflux a micturition cystogram will always have to be done. The diuretic effect of the contrast medium has to be taken into account. For a differential diagnosis mega-ureter has to be distinguished from functional distension (hypotonia) in the presence of infection or increased diuresis.